As we continue to review Your Wound Care Department Checklist for 2015 from the January 2015 column, we begin to understand the work necessary to be compliant from a clinical, operational, regulatory, and economic/financial (CORE) perspective (CORE is a proprietary process developed by the author). One area within the work list, mapping to all CORE areas, is the development of clinical order sets.
Diagnosing a specific wound type is a complex process. It takes accurate wound and skin assessment skill sets, which include an understanding of the physical findings of the wound and skin, and evaluating the patient’s laboratory values and diagnostic tests, nutritional needs, and management modalities, such as topical dressings or drugs, support surface products, and off-loading devices. An accurate plan of care is critical.
Clinical order sets (predefined templates) are one way to ensure patient safety and reduce risk. Creating order sets for the wound types seen in your department provides a common platform and support for clinical decisions related to a specific condition or medical procedure. Creating wound-specific laboratory values assists with the consistency of ordering and care.
Laboratory values are helpful in assessing and monitoring any chronic underlying medical conditions, as well as the patient’s nutritional status. These values should be evaluated on the first patient encounter to establish a baseline for care. In addition, if healing is not occurring as expected, these values can be tracked regularly to ensure that local and systemic factors are not contributing to poor healing. Important parameters to evaluate include protein levels, complete blood count, erythrocyte sedimentation rate, liver function tests, glucose and iron levels, total lymphocyte count, blood urea nitrogen and creatinine levels, lipoprotein levels, vitamin and mineral levels, and urinalysis. Even if only 1 deterrent is present, healing cannot occur.
Additional tools are available to assist the clinician to further define the diagnosis of the patient. For example, risk assessment tools are screening tools used as predictors to ensure systematic evaluation of individual risk factors. Risk assessment tools exist for areas of the skin at risk, such as pressure ulcers, diabetic foot ulcers, and clinical signs of venous disease. Nutritional risk assessment tools assist the practitioner in understanding the strategies necessary to identify the levels of nutritional risk. Manual risk assessment tools are integral in the prevention of many disease states. They include the ankle-brachial index, cultures, lower-leg and foot assessments, palpation of pulses/Doppler (ultrasound), segmental blood pressures, Semms-Weinstein monofilament test, transcutaneous oxygen tension, and vibration perception threshold assessment. Other diagnostic tests, such as laboratory values, radiologic studies, and vascular studies, should be taken into consideration when evaluating a patient at risk.
Organizing the various laboratory values and assessment data is helpful to maintain the knowledge base necessary to yield an accurate wound diagnosis. As an example, laboratory tests can be categorized in the following assessment data:
- Nutritional laboratory assessments
- ○ Albumin
- ○ Prealbumin
- ○ Transferrin
- ○ Total lymphocyte count
- ○ Vitamins
- ○ Minerals
- ○ Renal
- ○ Electrolytes
- ○ Glucose
- ○ Hepatic/hepatitis
- ○ Lipids
- ○ Hemoglobin A1c
- ○ Amylase/lipase
- ○ Iron/ferritin
- ○ Parathyroid hormone
- ○ Complete blood count with differential
- ○ Sedimentation rate
- ○ Glucose 6 phosphate dehydrogenase
- ○ Protein C/S
- ○ Fibrinogen/FDP/D-DIMERS
- ○ Prothrombin time/partial thromboplastin time
- ○ Cryoglobulins/cryofibrinogens
- ○ Antiphospholipid antibodies
- ○ Sickle cell
- ○ Serum protein electrophoresis
- ○ Antithrombin 3
To accurately manage the patient with a venous ulcer, the clinician would want to obtain nutritional laboratory values (as previously discussed), as well as a complete blood count. Additional laboratory tests to consider for the venous ulcer patient may include protein, total lymphocyte count, blood urea nitrogen, liver function tests, hemoglobin, and hematocrit.
Tests to consider when evaluating a patient with venous insufficiency include venography, Doppler, ankle-brachial index, plethysmography, and tissue biopsy.
Work with your medical director and staff to define the clinical order sets for your department. Remember, the clinical goal when evaluating a patient is confirmation of the diagnosis. Understanding the laboratory values and diagnostic tests, which support confirmation of the diagnosis, is critical. A single assessment parameter does not confirm a diagnosis. Carefully review the patient’s wound history, laboratory findings, diagnostic tests, and management modalities to support or place doubt on a tentative diagnosis based on case history data and clinical findings.